Multiple Surgical Teams in the O. R. at Once—Priority of Effort and Who Takes the Lead?

The management of a trauma patient with multiple injuries requires careful coordination prior to and while in the operating room. In order to consistently assure the best possible outcome for these patients a team-based approach is essential. Defining the relative roles for each team and the priority given to each injury is necessary to ensure a coordinated response and hence the best possible outcome. It is important that airway, breathing, and circulation remain the initial priorities and the correction of hemodynamic instability takes precedence over the workup of intracranial lesions. In turn, the management of intracranial injury takes precedence over the surgical fixation of broken bones. At times it is necessary for the trauma team and neurosurgery teams to work simultaneously in the operating room. An intracranial pressure monitor can be placed during laparotomy or thoracotomy in select cases, particularly when a preoperative CT scan cannot be obtained due to the urgent need for operative surgical resuscitation. Fortunately with the widespread and easy availability of around-the-clock CT scanning at most U.S. trauma centers, this is an uncommon scenario. High intracranial pressure can be treated medically until active systemic bleeding is controlled and the blood pressure is stabilized. A craniotomy for intracranial hematoma evacuation should be performed promptly after the hypotension has been corrected. Clear communication and coordination between the anesthesiologist, the trauma surgeon, the neurosurgeon, and other appropriate specialists are vital in order to obtain the best possible outcomes.